Could I have testicular atrophy given my symptoms of erectile dysfunction, low libido, and abnormal semen analysis, despite having elevated testosterone levels and improving luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels?

Assessment of Testicular Atrophy Risk

Based on your ultrasound measurements showing testicular volumes of 9ml bilaterally with lengths of 3.1-3.4cm, combined with elevated FSH levels (9.9-11 IU/L), you do have evidence of testicular atrophy that warrants further evaluation and proactive fertility preservation strategies. 1

Understanding Your Current Situation

Your clinical picture presents several contradictory findings that require careful interpretation:

Testicular Volume Assessment

• Testicular volumes of 9ml bilaterally represent mild testicular atrophy, as volumes less than 12ml are considered indicative of reduced testicular reserve 1
• The discrepancy between your two ultrasounds (4cm length with no volume stated versus 3.1-3.4cm with 9ml volumes) likely reflects measurement variability between operators, but the 9ml volume measurement is the more clinically relevant parameter 1
• Your perception of testicular softness and looseness may reflect actual changes in testicular consistency that accompany reduced spermatogenic function 1

Hormone Profile Interpretation

Your hormone results reveal a concerning pattern despite the seemingly "normal" testosterone:

• FSH levels of 9.9-11 IU/L indicate impaired spermatogenesis and primary testicular dysfunction, as FSH >7.6 IU/L is strongly associated with non-obstructive azoospermia or severe oligospermia 1, 2
• Your elevated LH (7.2-8.0 IU/L, at the upper limit of normal) indicates your pituitary is compensating for testicular resistance 1
• The paradoxically high testosterone (39.9 nmol/L) does NOT exclude testicular atrophy - this pattern suggests your Leydig cells (testosterone-producing cells) are still functioning while your seminiferous tubules (sperm-producing structures) are failing 1
• This dissociation between preserved Leydig cell function and impaired spermatogenesis is well-documented in progressive testicular dysfunction 1

Semen Analysis Findings

• Your sperm concentration of 60 million/ml is well above the WHO lower reference limit of 16 million/ml, which seems reassuring 1
• However, the yellow discoloration and low volume you described suggest possible inflammation or other pathology that requires investigation 3
• The combination of normal sperm count with elevated FSH and testicular atrophy indicates you have reduced testicular reserve despite currently adequate sperm production 1

Critical Next Steps

Immediate Diagnostic Workup

You need comprehensive semen analysis (at least two samples, 2-3 months apart) to assess not just concentration but also motility, morphology, and total motile sperm count 1, 4:

• Single analyses can be misleading due to natural variability 1
• Yellow semen and low volume warrant evaluation for infection, inflammation, or ejaculatory duct issues 3
• Request complete assessment including sperm motility, morphology, and white blood cell count 5

Measure a complete hormonal panel including LH, total testosterone, SHBG, and prolactin 4, 3:

• Calculate free testosterone index, as your elevated testosterone may be bound to SHBG and not bioavailable 3
• Check prolactin, as hyperprolactinemia can cause your exact symptom constellation of ED and low libido despite adequate testosterone 3, 6
• Repeat FSH measurement after addressing any metabolic stressors, as borderline FSH (9-12 IU/L) can normalize once acute illness or obesity resolves 4

Physical examination by a male reproductive specialist is essential 1:

• Assess for varicocele, which could be contributing to progressive testicular damage 1
• Evaluate testicular consistency and vas deferens/epididymal abnormalities 1
• Document body mass index, as obesity impairs the hypothalamic-pituitary-gonadal axis 4

Genetic Testing Considerations

If your repeat semen analysis shows severe oligospermia (<5 million/ml) or worsening parameters, you need genetic testing 1, 3:

• Karyotype analysis to exclude Klinefelter syndrome and other chromosomal abnormalities 1
• Y-chromosome microdeletion testing (AZFa, AZFb, AZFc regions) if sperm concentration drops below 5 million/ml 1

Fertility Preservation Strategy

Given your reduced testicular reserve (9ml volumes, elevated FSH), you should strongly consider sperm cryopreservation NOW while parameters remain adequate 1:

• Bank at least 2-3 separate ejaculates with 2-3 days abstinence between collections 1
• This provides insurance against progressive decline - once azoospermia develops, even microsurgical testicular sperm extraction only achieves 40-50% retrieval rates 1
• Each collection should be split into multiple vials to allow for staged use 1

Addressing Your Symptoms

Erectile Dysfunction and Low Libido

Your sexual symptoms despite high testosterone require specific investigation:

• Check prolactin levels urgently - hyperprolactinemia directly suppresses libido and causes ED independent of testosterone 3, 6
• If prolactin is elevated, MRI of the pituitary is necessary to evaluate for prolactinoma 3
• Consider free testosterone calculation, as high SHBG can reduce bioavailable testosterone despite normal total levels 3, 6
• Evaluate for metabolic factors including diabetes, obesity, and thyroid dysfunction that affect sexual function 7, 3

Yellow Semen and Low Volume

• Low semen volume (<1.4ml) with acidic pH suggests possible ejaculatory duct obstruction, though this typically presents with much lower sperm counts 3
• Yellow discoloration may indicate infection, inflammation, or increased white blood cells requiring treatment 3
• Request semen culture if infection is suspected 3

Critical Pitfalls to Avoid

NEVER start testosterone therapy for your ED or low libido symptoms 1, 4, 3:

• Exogenous testosterone will completely suppress your remaining spermatogenesis through negative feedback 1
• This can cause azoospermia that takes months to years to recover, if it recovers at all 1
• Your current testosterone is already elevated, making replacement therapy inappropriate 4

Do not delay fertility preservation 1:

• Your FSH levels and testicular volumes indicate you are at risk for progressive decline 1
• Banking sperm now, while counts remain adequate, is far superior to attempting sperm retrieval after azoospermia develops 1

Address reversible factors before making definitive diagnoses 4:

• Weight optimization if BMI >25 4
• Smoking cessation 3
• Correction of thyroid dysfunction or metabolic disorders 4
• Avoid heat exposure to testes (hot tubs, laptops on lap, tight underwear) 1

Treatment Considerations

If varicocele is found on examination, repair should be strongly considered given your testicular atrophy and elevated FSH 1:

• Varicocelectomy can halt progression of testicular atrophy and potentially reverse some damage 1
• 69% of men with poor sperm parameters had motile sperm after varicocele repair 1
• This intervention is most effective before irreversible testicular injury occurs 1

For fertility assistance if natural conception fails:

• Assisted reproductive technology (IVF/ICSI) offers superior pregnancy rates compared to empiric hormonal therapy 1, 4
• FSH analogue treatment has measurable but limited benefits and is not FDA-approved for idiopathic infertility 4
• Selective estrogen receptor modulators and aromatase inhibitors have limited benefits outweighed by ART advantages 1, 4

Monitoring Protocol

Repeat semen analysis and hormonal panel in 3-6 months 1, 4:

• Track whether parameters are stable or declining 1
• If sperm concentration approaches 20 million/ml or drops below 5 million/ml, urgently proceed with cryopreservation and genetic testing 1
• Monitor FSH, LH, testosterone, and prolactin trends 4